Antibiotic Prophylaxis for Surgical Procedures: Care of the Surgical Patient: Merck Manual Professional

Antimicrobial Preoperative Prophylaxis Guidelines
Category	Procedure	Adult Dosage*
Abdominal	Gastroduodenal surgery in patients with hemorrhage, cancer, obstruction, or other high-risk features	Cefazolin 1–2 g IV preoperatively or Clindamycin 600 mg plus gentamicin 120 mg IV preoperatively
	Gastric bypass	Cefazolin 1–2 g IV preoperatively
	Percutaneous gastrostomy	Cefazolin 1–2 g IV preoperatively
	Biliary tract (including ERCP) in patients who have acute symptoms, jaundice, or other high-risk features or who have had previous surgery	Cefazolin 1–2 g IV preoperatively or Gentamicin 80 mg IV preoperatively and q 8 h for 3 doses
	Appendectomy (without perforation)	Cefoxitin, cefotetan, or cefmetazole 1–2 g IV preoperatively and q 6 h for 3 doses or Metronidazole 500 IV mg plus gentamicin 1.5 mg/kg IV preoperatively
	Colorectal surgery, elective	Neomycin 1 g plus erythromycin base 1 g po at 1, 2, and 11 pm on the day before surgery ± parenteral drugs listed below for colorectal surgery
	Colorectal surgery, emergency	Cefoxitin, cefotetan, or cefmetazole 2 g IV preoperatively and q 4 h for 3 doses or Metronidazole 500 mg IV plus gentamicin 1.7 mg/kg IV preoperatively and q 8 h for 3 doses
Cardiac	Median sternotomy, coronary artery bypass graft surgery, valve surgery, or pacemaker insertion	Cefazolin 2 g IV preoperatively and q 4–6 h intraoperatively or Cefuroxime 1.5 g IV preoperatively and q 4–6 h intraoperatively or Vancomycin 1 g IV preoperatively
Neurosurgical	Craniotomy, high-risk only (eg, reexplorations, microsurgery, entry into sinuses or nasopharynx)	Vancomycin 1g IV plus gentamicin 1.5 mg/kg IV preoperatively or Cefazolin 1 g IV preoperatively
Neurosurgical	CSF shunt placement—only in hospitals with high infection rates (15–20%)	Trimethoprim 160 mg IV plus sulfamethoxazole 800 mg IV preoperatively and q 12 h for 3 doses or Vancomycin 10 mg plus gentamicin 3 mg injected into a cerebral ventricle
Noncardiac thoracic	Pneumonectomy, lobectomy, other resections, or esophageal surgery	Cefazolin 1–2 g IV preoperatively and q 6 h for 24 h or Vancomycin 1 g IV preoperatively
Obstetric-gynecologic	Cesarean delivery, high-risk only (eg, premature rupture of membranes)	Cefazolin 1 g IV after clamping cord and q 6 h for 2 doses
	Abortion, 2nd-trimester instillation	Cefazolin 1 g IV preoperatively and q 6 h for 2 doses
	Abortion, 1st trimester in patients with a history of pelvic inflammatory disease, gonorrhea, or multiple partners	Penicillin G 1–2 million units IV preoperatively and 3 h later or Doxycycline 100 mg po before the procedure and 200 mg ½ h afterward
	Hysterectomy, vaginal or abdominal	Cefazolin 1 g IV preoperatively and q 6 h for 2 doses or Doxycycline 200 mg IV preoperatively
Ophthalmic	Extraction of lens, with or without insertion of prosthesis	Gentamicin, tobramycin, or neomycin-gramicidin-polymyxin B drops over 2–24 h plus cefazolin 100 mg subconjunctivally at the end of the procedure
Orthopedic	Arthroplasty, including replacements	Cefazolin 1–2 g IV preoperatively and q 6 h for 3 doses or Vancomycin 1 g IV preoperatively
	Open reduction of fractures	Cefazolin 1 g IV preoperatively and as a single dose postoperatively
	Lower-extremity amputation (nonischemic)	Cefoxitin 2 g IV preoperatively and q 6 h for 4 doses
Otolaryngologic	Major head and neck surgery involving mucosa of the oral cavity or pharynx	Cefazolin 1–2 g IV preoperatively and q 8 h for 2 doses or Clindamycin 600–900 mg IV ± gentamicin 1.5 mg/kg IV preoperatively and q 8 h for 2 doses
Urologic	Prostatectomy if bacteriuria is present	Cefazolin 1 g IV preoperatively or another drug selected based on susceptibility tests
Urologic	Penile prosthesis insertion	Cefazolin 1 g IV preoperatively
Vascular	Lower-extremity or abdominal arterial surgery or lower- extremity amputation for ischemia	Cefazolin 1–2 g IV preoperatively and q 6 h for 24 h or Vancomycin 1 g IV preoperatively and 12 h after the procedure
*Drugs, dosages, routes, and frequencies given represent recent expert recommendations. Cefazolin remains highly favored because of its spectrum of bactericidal activity, long half-life, low cost, and low toxicity. Alternatives are primarily for patients with β-lactam allergies.
± = with or without.
Adapted from Kernodle DS, Kaiser AB: Postoperative infections and antimicrobial prophylaxis. In Principles and Practice of Infectious Diseases, ed 5, edited by GL Mandell, JE Bennett, and R Dolin. New York, Churchill Livingstone, 2000, pp. 3186–3187 and from Antimicrobial prophylaxis in surgery. The Medical Letter 37:79–82, 1995.

Antimicrobial Preoperative Prophylaxis Guidelines

Category

Procedure

Adult Dosage*

Abdominal	Gastroduodenal surgery in patients with hemorrhage, cancer, obstruction, or other high-risk features	Cefazolin 1–2 g IV preoperatively or Clindamycin 600 mg plus gentamicin 120 mg IV preoperatively
	Gastric bypass	Cefazolin 1–2 g IV preoperatively
	Percutaneous gastrostomy	Cefazolin 1–2 g IV preoperatively
	Biliary tract (including ERCP) in patients who have acute symptoms, jaundice, or other high-risk features or who have had previous surgery	Cefazolin 1–2 g IV preoperatively or Gentamicin 80 mg IV preoperatively and q 8 h for 3 doses
	Appendectomy (without perforation)	Cefoxitin, cefotetan, or cefmetazole 1–2 g IV preoperatively and q 6 h for 3 doses or Metronidazole 500 IV mg plus gentamicin 1.5 mg/kg IV preoperatively
	Colorectal surgery, elective	Neomycin 1 g plus erythromycin base 1 g po at 1, 2, and 11 pm on the day before surgery ± parenteral drugs listed below for colorectal surgery
	Colorectal surgery, emergency	Cefoxitin, cefotetan, or cefmetazole 2 g IV preoperatively and q 4 h for 3 doses or Metronidazole 500 mg IV plus gentamicin 1.7 mg/kg IV preoperatively and q 8 h for 3 doses
Cardiac	Median sternotomy, coronary artery bypass graft surgery, valve surgery, or pacemaker insertion	Cefazolin 2 g IV preoperatively and q 4–6 h intraoperatively or Cefuroxime 1.5 g IV preoperatively and q 4–6 h intraoperatively or Vancomycin 1 g IV preoperatively
Neurosurgical	Craniotomy, high-risk only (eg, reexplorations, microsurgery, entry into sinuses or nasopharynx)	Vancomycin 1g IV plus gentamicin 1.5 mg/kg IV preoperatively or Cefazolin 1 g IV preoperatively
Neurosurgical	CSF shunt placement—only in hospitals with high infection rates (15–20%)	Trimethoprim 160 mg IV plus sulfamethoxazole 800 mg IV preoperatively and q 12 h for 3 doses or Vancomycin 10 mg plus gentamicin 3 mg injected into a cerebral ventricle
Noncardiac thoracic	Pneumonectomy, lobectomy, other resections, or esophageal surgery	Cefazolin 1–2 g IV preoperatively and q 6 h for 24 h or Vancomycin 1 g IV preoperatively
Obstetric-gynecologic	Cesarean delivery, high-risk only (eg, premature rupture of membranes)	Cefazolin 1 g IV after clamping cord and q 6 h for 2 doses
	Abortion, 2nd-trimester instillation	Cefazolin 1 g IV preoperatively and q 6 h for 2 doses
	Abortion, 1st trimester in patients with a history of pelvic inflammatory disease, gonorrhea, or multiple partners	Penicillin G 1–2 million units IV preoperatively and 3 h later or Doxycycline 100 mg po before the procedure and 200 mg ½ h afterward
	Hysterectomy, vaginal or abdominal	Cefazolin 1 g IV preoperatively and q 6 h for 2 doses or Doxycycline 200 mg IV preoperatively
Ophthalmic	Extraction of lens, with or without insertion of prosthesis	Gentamicin, tobramycin, or neomycin-gramicidin-polymyxin B drops over 2–24 h plus cefazolin 100 mg subconjunctivally at the end of the procedure
Orthopedic	Arthroplasty, including replacements	Cefazolin 1–2 g IV preoperatively and q 6 h for 3 doses or Vancomycin 1 g IV preoperatively
	Open reduction of fractures	Cefazolin 1 g IV preoperatively and as a single dose postoperatively
	Lower-extremity amputation (nonischemic)	Cefoxitin 2 g IV preoperatively and q 6 h for 4 doses
Otolaryngologic	Major head and neck surgery involving mucosa of the oral cavity or pharynx	Cefazolin 1–2 g IV preoperatively and q 8 h for 2 doses or Clindamycin 600–900 mg IV ± gentamicin 1.5 mg/kg IV preoperatively and q 8 h for 2 doses
Urologic	Prostatectomy if bacteriuria is present	Cefazolin 1 g IV preoperatively or another drug selected based on susceptibility tests
Urologic	Penile prosthesis insertion	Cefazolin 1 g IV preoperatively
Vascular	Lower-extremity or abdominal arterial surgery or lower- extremity amputation for ischemia	Cefazolin 1–2 g IV preoperatively and q 6 h for 24 h or Vancomycin 1 g IV preoperatively and 12 h after the procedure
*Drugs, dosages, routes, and frequencies given represent recent expert recommendations. Cefazolin remains highly favored because of its spectrum of bactericidal activity, long half-life, low cost, and low toxicity. Alternatives are primarily for patients with β-lactam allergies.
± = with or without.
Adapted from Kernodle DS, Kaiser AB: Postoperative infections and antimicrobial prophylaxis. In Principles and Practice of Infectious Diseases, ed 5, edited by GL Mandell, JE Bennett, and R Dolin. New York, Churchill Livingstone, 2000, pp. 3186–3187 and from Antimicrobial prophylaxis in surgery. The Medical Letter 37:79–82, 1995.